Surgical Checklists

Tagged Checklist, Audit, SurgicalPerformance, Complications; Posted 12 years ago

Surgical Checklists demonstrated a significant reduction in postoperative morbidity and mortality in more than one very large study.

The first study was conducted by WHO with a heavy focus on the quality of surgery in countries of the developing world and published in January 2009 (Haynes AB et al; N Engl J Med 2009; 360(5):491ff). The group of authors collected data on clinical processes and outcomes from almost 8000 patients. After the introduction of a checklist the perioperative death rate reduced from overall 1.5% to 0.8%. Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist. The study is often criticized because of severe shortcomings: The study design was not randomised but compared outcomes before and after the intervention. Confounding factors that could have influenced outcomes were not considered. And finally, hospitals which strictly adhered to the checklist had no improvement in outcomes whereas hospitals with bad compliance had great improvements. Nevertheless this study was considered exemplary by the Royal Australian College of Surgeons and has been used by healthcare administrators to hand down surgical checklists in Australian hospitals.

The second significant study was from Holland and overcomes most of the shortcomings from the above WHO study (de Vries EN, et al. N Engl J Med 2010;363:1928-37). The Dutch study developed 11 checklists and examines nearly 100 items, which are briefly displayed in table 1 below. The checklists apply not only to the operating theatre but also cover pre- and postoperative areas, the ward, the surgeon, anaesthetist and nursing staff. Most importantly, the study included a control group. The results are very conclusive: Audit reduced the proportion of patients with at least one complication from 15.4 to 10.6%. Consistent with the WHO study, perioperative mortality dropped from 1.5 to 0.8%. In this study, compliance with the checklist did correlate with improvements in health outcomes. Patients with incomplete checklists had significantly more complications than those for whom checklists were completed. This study is proof that checklists work and decrease not only the risk for surgical complications but also death from surgery.

However, the way mandatory checklists are run in most hospitals that I operate, serves mostly the hospital administrators rather than surgeons and patients. Someone reads out loud some stuff that makes no sense at all, often is misspelled and factually wrong. By contrast, checklists should trigger a thinking process about the meaning of its items and the issues that are addressed in that particular surgical case.

A transcript of a typical time out using a checklist reads like this. “We have name name here, UR number 65433121. Patient consented to FYH, avarian prosecution, with or without f slash s and minus or plus proceeds. Antibiotics are in. Consent signed.” You think I made this up. You should have been in my theatre yesterday and watch.   

I truly believe checklists are great. They help reduce human errors that can occur as a consequence of limited human memory. Before we take a patient into the operating theatre, there are a large number of tasks to complete in a specific order; they are all important and omission can lead to errors. By going though the checklist ensures consistency and completeness of a series of tasks that are to many to remember.

Unfortunatley, checklists are often exercised the wrong way. That’s why their implementation into our hospitals has been slow and with some apprehension. The time out that I have given above means absolutely nothing. It is devoid of all meaning. It does not do checklists a favour.

What’s the solution? While I have to agree to through the (useless) checklist at my hospital, nobody will argue with you if you want to run your own checklist in addition to the official hospital checklist.  Below I give some hints how to develop those “private” checklists that you can use whether you work in the public or in a private hospital system.

How do surgical checklists work?

In short: No one really knows. There are direct effects and indirect effects.

Direct effects: If a specialist forgets to take a “blood group and hold” and the patient sustains a vascular injury, the blood loss would be higher, which could cause further problems (respiratory failure, wound breakdown, cerebral oedema, etc).

Indirect effect: If a surgical team realises that a case is subject of review, the entire team would focus very hard on the case and try to get every detail right (“Hawthorne effect”). The checklist would counteract the effects from “normal” distraction.

Are checklists specific to the environment?

They most definitely are. I suggest that you accept that checklists are essential and current standard. You will also need to accept that checklists need to cover more than just the operating theatre. However, the environment you work in (public vs. private; what resources are available to you; etc) will definitely shape the checklist that makes most sense for you.

I work part time in a public hospital and as such I have no ownership of the checklist that we run at that hospital. I am just a very small wheel as part of a big organisation and I will fulfil my part to the best of my abilities. The checklist, which the health department supports is available in that hospital.

I also work as a private practitioner (visiting medical officer; VMO) at a private hospital. I am not employed by the hospital. My practice is organised through my surgery. I employ staff to assist me. While I am entitled to very little support through the hospital, my VMO status leaves me freedom how to run my practice. In theatre we still use the (WHO) hospital checklist. In addition, I run my own checklists independently. The overlap of those checklists is minimal. Below is the checklist developed by SurgicalPerformance.

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